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CASE
 Mrs Ford is a 29 years old lady who has been complaining of
vaginal discharge for the past 3 days. Otherwise she is
asymptomatic. Her PMH includes bronchial asthma. Her cycles
are normally regular with no issues. She has been with her
current partner for few months. ON examination there was no
significant findings.
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What do you want to know more?
What is your differential?
What investigations would you like to do, if any?
What are the treatment options?
What is your plan if this is a recurrent problem?
Can you suggest any preventive measures?
Causes
 Non-infective:
 Physiological
 Cervical polyps and ectopy
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Foreign bodies, e.g. retained tampon
Vulval dermatitis
Erosive lichen planus
Genital tract malignancy
 Fistulae
 Non-sexually transmitted infection:
 Bacterial vaginosis
 Candida
 Sexually transmitted infection:
 Chlamydia trachomatis
 Neisseria gonorrhoeae
 Trichomonas vaginalis
Assessment
 A full clinical and sexual history
 Nature of the discharge: odour, onset, duration, colour.
 Associated symptoms: itch, dyspareunia, dysuria,
abdominal pain, abnormal bleeding, pyrexia.
 Medications: antibiotics, steroids
 PMH: DM, immunocompromised state.
 Investigations: Triple swaps, vaginal pH testing
(Candida and bacterial vaginosis can be diagnosed
clinically and treated without sampling)
Bacterial Vaginosis
 May be asymptomatic (in up to 50% of women)
 Thin, profuse and fishy smelling discharge without itch or
soreness
 Associated with poor pregnancy outcomes, endometritis
after miscarriage, and pelvic inflammatory disease
 Asymptomatic bacterial vaginosis in non-pregnant women
does not require treatment.
 Routine: oral metronidazole for 5-7 days or stat 2gm dose.
Alternatively topical metronidazole or oral clindamycin or
topical clindamycin.
 70-80 % cure rate but commonly recurs
Candidiasis
 Thick, white, non-offensive discharge which is
associated with vulval itch and soreness.
 May cause mild dyspareunia and external dysuria
 Examination may be normal or there may be erythema,
oedema and fissuring
 pH is less than 4.5
 Asymptomatic vulvovaginal candidiasis does not need
treatment.
 Vaginal imidazole: clotrimazole, econazole, miconazole or
fluconazole 150 mg orally (avoid in pregnancy)
 80-95 % cure rate.
Infective (STD) vaginal discharge
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Can present with vaginal discharge but may also be asymptomatic.
Associated with an increased risk of HIV transmission.
May be complicated by PID.
 Trichomonas vaginalis:
 Offensive yellow vaginal discharge, which is often profuse and frothy, with
vulval itch and soreness, dysuria, abdominal pain and superficial dyspareunia
 Is associated with preterm delivery
 Chlamydia trachomatis:
 Copious purulent vaginal discharge, but it is asymptomatic in 80% of women
 Diagnosis is confirmed on swabbing
 Neisseria gonorrhoeae:
 Purulent vaginal discharge but is asymptomatic in up to 50% of women
 Mild symptoms include slight discharge, dysuria, intermenstrual bleeding
Treatment (infective STD discharge)
 Refer to the GUM clinic (unless your practice has the
appropriate expertise).
 Chlamydia trachomatis; doxycyclin or azithromycin
 Gonorrhoea; cefixime or ceftriaxone
 Trichomonas vaginalis; metronidazole
 Patients will be fully screened for concurrent STDs and
treated as appropriate.
 Partners will need to be identified, screened and
treated too.
Recurrent discharge
 Ensure pathology hasn't been missed (e.g. an STD in the
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case of a patient being treated for bacterial vaginosis).
Explore personal hygiene (douches, perfumed products
and tight synthetic clothing)
If the patient has coil in situ, consider alternative.
Think of diabetes, immunosuppression or antibiotic
administration.
Consider the 'silent' complaint: depression, anxiety or
psychosexual dysfunction.
Post-menopausal atrophic changes may predispose women
to recurrent vaginitis.